The story of living in spite of melanoma, CLND (X 2!), metastasis, vaccines, anti-PD-1, lung removal, and stereotactic radiation. (With a little adenocarcinoma ex-goblet cell carcinoid thrown in!!!) The story of life with family and friends. {Posts under ~ Sew Chaotically, Travel Chaotically, and Chaotic Cookery also housed within! A girl's gotta have fun!}

About Me

Who am I? That is a question the rest of you could probably answer better than I. I am a wife, mother, daughter, sister, friend, pediatric nurse practitioner, cook, teacher, gardener, lover of words and music, occasional seamstress, and homemaker. I do have a couple of talents of questionable merit: I can create a decent meal in less than 30 minutes. I can feed and/or soothe almost any baby. And I can remember practically any song I've ever heard. For the rest, I'd rather those who know me decide.

Immunotherapy experienced
impressive progresses in cancer treatment. Antibodies against PD-1 improved
survival in different types of cancer including melanoma. They are generally
well tolerated. However, skin toxicities including pruritus, rashes and
vitiligo are reported. Although frequent, they are have not been further
characterized yet. In this analysis we aimed to systematically assess and
characterize the adverse cutaneous reactions observed in melanoma patients
treated with anti-PD-1 antibodies.

Immune checkpoint inhibitors
targeting cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) and programmed
cell death protein 1 (PD-1) have been recently approved for treatment of
patients with metastatic melanoma and non-small cell lung cancer (NSCLC).
Despite important clinical benefits, these therapies are associated with a
diverse spectrum of immune-related adverse events (irAEs) that are typically
transient, but occasionally severe or even fatal.

This autopsy case illustrates
that clinically overt irAEs may represent only a fraction of the total spectrum
of immune-related organ pathology in patients treated with immune checkpoint
inhibitors. We report a comprehensive analysis of systemic irAE pathology based
on the autopsy of a 35-year-old female patient with metastatic melanoma treated
first with ipilimumab and then nivolumab. The clinical course was characterized
by a mixed tumor response with regression of skin and lung metastases and fatal
progression of metastatic disease in the small bowel, peritoneum and brain.
During therapy with ipilimumab, radiographic features of immune-related
pneumonitis were noted. The autopsy examination established a sarcoid-like
granulomatous reaction of the lung, pulmonary fibrosis and diffuse alveolar
damage. Importantly, a clinically unapparent but histologically striking
systemic inflammation involving the heart, central nervous system, liver and
bone marrow was identified. Severe immune-related end-organ damage due to
lymphocytic myocarditis was found.

Autopsy studies are an
important measure of quality control and may identify clinically unapparent
irAEs in patients treated with immunotherapy. Pathologists and clinicians need
to be aware of the broad spectrum of irAEs for timely management of
treatment-related morbidity.

Targeted immunotherapy has
markedly improved the survival of melanoma patients. We report the case of a
melanoma patient who developed a collagenous colitis under an anti-PD1 regimen.
A 68-year-old woman was treated for a stage IV melanoma. An anti-PD1,
pembrolizumab, was introduced after the failure of a first-line therapy with an
anti-CTLA4. At cycle 14, pembrolizumab was interrupted because of grade 3 diarrhea.
Histologic analysis of colon mucosa showed a thickened apical subepithelial
collagen layer with irregular collagen deposition of more than 25 µm thickness.
Budesonide 9 mg/day and cholestyramin 8 g/day were then introduced, leading to
a decrease in the number of stools to grade 2. Because of the prognosis of the
disease, the efficacy of pembrolizumab in this patient and the lack of other
efficient treatments, pembrolizumab was restarted, with no worsening of the
diarrhea after a follow-up of 8 weeks. In the era of immunotherapy, a new type
of drug-induced colitis has emerged because of monoclonal antibodies targeting
immune checkpoints such as CTLA-4 and PD1. Gastrointestinal tract
immune-mediated adverse effects are now well described with ipilimumab. To the
best of our knowledge, this is the first report of a collagenous colitis in a
patient treated with pembrolizumab, thus suggesting a new mechanism of
toxicity. Classically, collagenous colitis first-line treatment is based on
discontinuation of the suspected treatment. However, there may be a strong
benefit to maintaining an anti-PD1 regimen in our patients. In this case,
symptomatic management associated with budesonide and cholestyramin enabled
continuation of pembrolizumab.

Immunotherapy has become a
mainstay in the treatment of metastatic melanoma. Cytotoxic
T-lymphocyte-associated antigen-4 (CTLA-4) inhibitors and programmed death-1
(PD-1) inhibitors, which have been added more recently, represent two of the
main classes of immunomodulating agents. PD-1 inhibitors are well tolerated
and are known to have a decreased rate of occurrence of adverse effects
compared with CTLA-4 inhibitors. However, the risk remains for serious
immune-mediated adverse reactions. Given their long half and extended
efficacy, treatment with a CTLA-4 inhibitor before use of a PD-1 inhibitor
may increase the risk of adverse effects. In addition, caution should be
exercised when rechallenging grade 3 or 4 adverse effects with the same agent
or a different agent of the same class. The re-emergence of a previous
toxicity may occur or, as found in this case, a new severe effect may arise.
This article will present a case of
fatal immune-related hepatoxicity in a patient treated with a CTLA-4
inhibitor, followed by treatment with a PD-1 inhibitor.

Nivolumab (ONO-4538) is an
anti-programmed death-1 specific monoclonal antibody, which has become a
standard treatment for metastatic malignant melanoma. Nivolumab induces
autoimmune adverse events, defined as immune-related adverse events. Herein, we
report a case of nivolumab-induced thyroid dysfunction in the clinical setting.
Fourteen patients were treated with nivolumab at our institute, of which three
developed thyroid dysfunction, an incidence higher than previously reported in
the initial clinical trials. Interestingly, one patient achieved complete
remission; suggesting that in some patients, the occurrence of immune-related
adverse events, including thyroid dysfunction, might reflect the drug's
antitumour efficacy. No patient died or discontinued nivolumab treatment owing
to thyroid dysfunction. Although thyroid dysfunction first appeared to be
asymptomatic, two of the three patients developed symptoms related to
hypothyroidism soon after, requiring hormone replacement therapy. Another
patient developed hyperthyroidism that was initially asymptomatic; the patient
subsequently developed myalgia with fever >39.5°C after two additional
courses of nivolumab. Treatment with nivolumab was therefore discontinued, and
treatment with prednisolone was initiated. Symptoms resolved within a few days,
and thyroid function normalized. Thyroid dysfunction is sometimes difficult to
diagnose because its symptoms similar to those of many other diseases. In
addition, thyroid-related immune-related adverse events may present with unique
symptoms such as myalgia with high fever, abruptly worsening patients' quality
of life. Consequently, thyroid dysfunction should be considered as a possible
immune-related adverse event. Thus, it is important to test for thyroid
dysfunction at baseline and before the administration of each nivolumab dose if
possible.

Novel immunotherapies are
increasingly being used to treat malignant melanoma. The use of such agents has
been associated with triggering autoimmunity. However, there has been a paucity
in reports of limbic encephalitis associated with these immunotherapies.
Pembrolizumab, a monoclonal antibody against programmed cell death antigen
(PD-1), is currently being trialled in the UK to treat malignant melanoma. We
report a unique case of antibody-negative limbic encephalitis presenting 1 year
after starting pembrolizumab, in the context of malignant melanoma. The patient
presented with progressive cognitive decline. MRI of the brain revealed signal
change within the limbic structures. Cerebrospinal fluid studies confirmed
evidence of inflammation with raised white cell count and protein. We were able
to prevent further progression of symptoms by stopping pembrolizumab and
treating the patient instead with steroids. We advocate considering autoimmune
neuroinflammation as a differential for neurological disorders presenting in
patients receiving PD-1 antagonist treatment and immunotherapy in general.

I
don't want to frighten anyone with all the crazy events documented
here. Overall, anti-PD1 products have minimal side effects compared to
many other cancer treatments. However, I published these so that should
any "strange" things start happening to you after, or during, anti-PD1
therapy, you can speak with your doctor and get them checked out as
quickly as possible. After all, as Dr. Weber mused YEARS ago, 'This stuff is weird!" - c

Tuesday, March 29, 2016

Here is a list (not at all comprehensive!) of abbreviations frequently used in melanoma discussions per the request of a melanoma patient on the MRF forum having trouble getting through the acronyms. It was fairly well received (though I'm not sure everyone read the ENTIRE list!!!) so I thought I would share it here:

NED - no evidence of disease

NEAD - no evidence of active
disease (a rather new acronym in melanoma world)

Mets - metastatic disease

SLN - sentinel lymph node
(the node most proximal to the lesion)

WLE - wide local excision
(the area of tissue to remove around a lesion to provide standardized
accepted clear margins)

CLND - complete lymph node
dissection (removal of all nodes in local area)

SRS - stereotactic radio
surgery (radiation beamed in to one area from a variety of vantage points so
surrounding tissue has minimal damage)

WBR - whole brain radiation

Immunotherapy - treatment
that stimulates the immune system to attack tumors (types below)

BRAF or NRAS or CKIT ....some
labels for different variations in tumors

BRAFi - BRAF inhibitors - meds
for folks with those mutations

MEK - another place to block
tumor metabolism.MEKi (MEK inhibitors)
have been found to make BRAFi work better, last longer, with fewer side effects
and so are most often prescribed with BRAF inhibitors.

PR - partial response

CR - complete response

SD - stable disease

ORR - overall response rate

DFS - disease free survival

PFS - progression free survival

OS - overall survival

DLT - dose limiting toxicity

AE - adverse event

Ir AE - immune related
adverse event

WTF - whiskey tango foxtrot -
you gotta have a sense of humor!

(Folks.....if you like
this...please refer folks back to this cause...IDHTS (I don't have the
strength!) To type this again!

Hope this helps. Wishing you
all my best. Celeste

I crack myself up!!! Hee hee!!! Later I shared it with a friend; watching her face as she read it through. Her eyes widened and she looked up at me!! "You really are you!!! All the time!" Yep! That's all I got, so I guess I'll stick with it. And...while I don't for one moment believe that positivity will cure cancer, a sense of humor will sure make it a little less painful.

Obviously,
I still blog (and occasionally share on the melanoma forums) the latest data in melanoma research. It takes a
great deal of time and effort. At times I long to stop. Still, I
know I have access to information that others do not. And...perhaps...the
ability to share it in ways that makes it a bit more comprehensible to
others. I receive frequent emails from folks looking for additional
information. Those are a mixed bag. Some incredibly demanding and
critical. Not long ago a writer really said...."I guess I could actually read your blog and find the answers to my questions, but, are you the one who had melanoma or what?" (Wow!!! The answer to that one seems pretty clear at the very top of the page! Not that she stopped there!!!) Others are clearly desperate or utterly confused. Some
intelligent, thoughtful and appreciative. Still others never bother with
a thank you or kiss my foot (including the one mentioned above!!!). But, many have become dear friends. A mixed
bag indeed!! And, yes. Against the advice of some who care about me....I answer them all. Melanoma doesn't make you nice or smart....folks are....or aren't. But, it can make you out of your mind with worry and fear...so I try to give folks a chance. And before you start feeling sorry for me....or get the impression that I am feeling sorry for myself....the support of many...especially 'MY boys!!!' - Josh, Ed, Mat, Jonathan, Paul,
Steven, John, Eric, and Brian helps keep me going and can make me laugh out
loud. Many others will live in my heart forever. In total...a much greater gift to me, than any I have given.

Saturday, March 26, 2016

Biomarkers. Sounds important. What are they? What can they really tell us?

Researchers
have been seeking to find a connection between nonspecific biomarkers
(things we ALL have circulating in our blood) like LDH, various white
blood cells (neutrophils and monocytes - whether as an absolute count or
as a neutrophil to lymphocyte ratio), myeloid-derived suppressor cells
(MDSCs) and T-regs (See post with links about all that here: Blood markers associated with clinical outcomes). And
while many meaningful correlations have been drawn between these
components and response to treatment (or lack thereof); the fact that
they are all affected by numerous circumstances other than melanoma and
its treatment, create limitations in the clarity with which they can be
used to PREDICT responses.

With recent scientific advances, PCR testing (Polymerase chain reaction) has become more efficientand cost-effective, allowing labs to copy or "amplify"
small segments of DNA or RNA though screening blood or other biological
specimens. This ability allows the cellular identification of whatever
may be floating in that blood sample....whether it is a virus or
fungus, or actual bits and pieces of tumor cells themselves, to allow a
determination of disease burden, prognosis, and response to treatment.
Here is an earlier post: Circulating tumor cells: how they may eventually impact melanoma diagnosis and evaluation of response

Cutaneous
melanoma is one of the highest incident-rate cancers with increasing
prevalence in Western societies. Despite the advent of new approved
therapeutics, the 5-year overall survival rate of stage IV melanoma
patients remains below 15%. Current treatments for late stage disease
have shown higher efficacy when treated at a lower disease burden. Thus,
blood-based biomarkers capable of detecting melanoma prior to
clinically evident distant metastasis, will improve the treatment and
outcomes for melanoma patients. To that end, effective treatment of
melanoma necessitates identification of patients at risk for developing
distant metastases. Furthermore, employing blood biomarkers that monitor
cancer progression over the course of treatment is a promising solution
to post-treatment drug resistance often developed in melanoma patients.
Non-invasive blood biomarker assays allow for regular dynamic
monitoring of disease. "Liquid Biopsy" of blood, which exploits
circulating tumor cells (CTCs), cell-free circulating tumor DNA (ctDNA)
and cell-free circulating microRNA (cmiRNA), has been shown to detect
prognostic factors for relapse in AJCC stage III and stage IV melanoma
patients. Moreover, molecular characterization of CTC and analysis of
various forms of ctDNA present promising potential in development of
individualized therapy for melanoma patients. New approaches such as
massive parallel sequencing (MPS) provide a comprehensive view of the
disease progression, allowing for the selection of therapeutic options
for individual patients. With advancements of improving molecular
assays, liquid biopsy analysis as a powerful, routine clinical assay for
melanoma patients, is highly promising prospective.

TNM staging is mainly used to
evaluate the prognosis of melanoma patients. Serum biomarkers such as
5-S-cysteinyldopa (5-S-CD) have occasionally been used but most do not respond
until the tumour burden becomes high. Recently, circulating melanoma cells
(CMC) have been reported as a possible new biomarker to detect metastasis,
monitor treatment response and predict prognosis. The object of this
exploratory study was to evaluate the efficacy of CMC to detect metastasis and
predict prognosis by cross-sectional and prospective observational analyses,
respectively. Altogether 15 patients with stages II-IV melanoma were enrolled
and CMC were enumerated by CellSearch system with cut-off values of two
cells/7.5 mL. Serum 5-S-CD and lactate dehydrogenase (LDH) were also measured.
The sensitivity of CMC and 5-S-CD for the detection of metastasis was 33 and
50%, respectively. The combination of CMC and 5-S-CD showed a sensitivity of
67%, the best performance among CMC, 5-S-CD, LDH and any combination of two of
the markers. Additionally, a 30-month prospective observation showed that CMC
could segregate patients with poorer prognosis. The median survival time for
the patients with less than 2 CMC and those with greater than or equal to 2 CMC was 19.5 and 4.5 months,
respectively. The limitation of this study is the small sample size. These
preliminary results indicate CMC may complement the efficacy of 5-S-CD to
detect metastasis and can be a prognostic marker. Although there is still room
for improvement to maximize the sensitivity, the CellSearch system is
reproducible, standardized and suitable for multi-center studies.

Then,
there's the examination of the properties of the tumor sample itself.
This article talks about looking at the tumor in regard to how well it
is being recognized by the immune system....specifically t-cells:

Anti-PD-1 therapy yields objective clinical responses
in 30-40% of advanced melanoma patients. Since most patients do not respond,
predictive biomarkers to guide treatment selection are needed. We hypothesize
that MHC-I/II expression is required for tumour antigen presentation and may
predict anti-PD-1 therapy response. In this study, across 60 melanoma cell
lines, we find bimodal expression patterns of MHC-II, while MHC-I expression
was ubiquitous. A unique subset of melanomas are capable of expressing MHC-II
under basal or IFNγ-stimulated conditions. Using pathway analysis, we show that
MHC-II(+) cell lines demonstrate signatures of 'PD-1 signalling', 'allograft
rejection' and 'T-cell receptor signalling', among others. In two independent
cohorts of anti-PD-1-treated melanoma patients, MHC-II positivity on tumour
cells is associated with therapeutic response, progression-free and overall
survival, as well as CD4(+) and CD8(+) tumour infiltrate. MHC-II(+) tumours can
be identified by melanoma-specific immunohistochemistry using commercially available antibodies
for HLA-DR to improve anti-PD-1 patient selection.

Here...the tumor is being characterized by surface molecules that are correlated with prognosis:

Sentinel lymph node status is a major prognostic
marker in locally invasive cutaneous melanoma. However this procedure is not
always feasible, requires advanced logistics, and carries rare but significant
morbidity. Previous studies have linked markers of tumour biology to patient
survival. In this study we aimed to combine the predictive value of established
biomarkers in addition to clinical parameters as indicators of survival in
addition to or instead of sentinel node biopsy in a cohort of high risk
melanoma patients. Patients with locally invasive melanomas undergoing sentinel
lymph node biopsy were ascertained and prospectively followed. Information on
mortality was validated through the National Death Index. Immunohistochemistry
was used to analyse proteins previously reported to be associated with melanoma
survival, namely Ki67, p16, and CD163. Evaluation and multivariate analyses
according to REMARK criteria were used to generate models to predict
disease-free and melanoma-specific survival. 189 patients with available archival
material of their primary tumour were analysed. Our study sample was
representative of the entire cohort (N=559). Average Breslow thickness was 2.5
mm. 32 (17%) patients in the study sample died from melanoma during the
follow-up period. A prognostic score was developed and was strongly predictive
of survival, independent of sentinel node status. The score allowed
classification of risk of melanoma death in sentinel node negative patients.
Combining clinicopathological factors and established biomarkers allows
prediction of outcome in locally invasive melanoma and might be implemented in
addition to or in cases when sentinel node biopsy cannot be performed.

PD-1 immune checkpoint
blockade provides significant clinical benefits for melanoma patients. We
analyzed the somatic mutanomes and transcriptomes of pretreatment melanoma
biopsies to identify factors that may influence innate sensitivity or
resistance to anti-PD-1 therapy. We find that overall high mutational loads
associate with improved survival, and tumors from responding patients are
enriched for mutations in the DNA repair gene BRCA2. Innately resistant tumors
display a transcriptional signature (referred to as the IPRES, or innate
anti-PD-1 resistance), indicating concurrent up-expression of genes involved in
the regulation of mesenchymal transition, cell adhesion, extracellular matrix
remodeling, angiogenesis, and wound healing. Notably, mitogen-activated protein
kinase (MAPK)-targeted therapy (MAPK inhibitor) induces similar signatures in
melanoma, suggesting that a non-genomic form of MAPK inhibitor resistance
mediates cross-resistance to anti-PD-1 therapy. Validation of the IPRES in
other independent tumor cohorts defines a transcriptomic subset across distinct
types of advanced cancer. These findings suggest that attenuating the
biological processes that underlie IPRES may improve anti-PD-1 response in
melanoma and other cancer types.

While none of these (other than those that are simple measures of recognized blood components) are validated and ready for daily screening of cancer patients across this country....every step is important in helping docs...eventually....determine
the best treatment options for the individual and monitor their
response to that treatment in ways that are specific, easily measured,
and less invasive and damaging to that patient. What a beautiful day that will be!!! Minimized only by the day we figure out how to avoid cancer entirely! Hey....might as welllive large and dream big!!! - c

Thursday, March 24, 2016

This pattern is ancient. But, the darts to front and back make it fit much nicer than it appears it would. The material is a cotton from Hancocks that I got last year that is soft but substantial, with a little slub and faint pin stripe. I know, I know! It's ANOTHER grey skirt! But look what it can do!

My favorite blues...

Classic with a twist in the fabric of the blouse...

You know I LOVE me some stripes. Especially with a fav scarf Roo got me on her visit to Kew Gardens, London.

Pink and ruffles....done right....are always good!!!

I had fun with this one. Perhaps I missed my calling as a window dresser or stylist. Or perhaps I like playing with a life size Dawn Doll!!! Anyhow....I do like these outfits. They meet my own challenge of choosing to make things that I really like to wear, rather than choosing items based on whether or not I think they would be easy to make. Although this one WAS super easy....AND....I made NONE of these tops....AND....that is OK with me!!!! Have fun and sew chaotically!!! - c

We previously reported that
talimogene laherparepvec, an oncolytic herpes virus encoding
granulocyte-macrophage colony-stimulating factor (GM-CSF), resulted in an
objective response rate of 26 % in patients with advanced melanoma in a
phase II clinical trial. The response of individual lesions, however, was not
reported. Since talimogene laherparepvec is thought to mediate anti-tumor
activity through both direct tumor cytolysis and induction of systemic
tumor-specific immunity, we sought to determine the independent response rate
in virus-injected and non-injected lesions. Fifty patients with stage
IIIC or IV melanoma were treated with talimogene laherparepvec in a
multi-institutional single-arm open-label phase II clinical trial. In this
study patients were treated until a complete response was achieved, all
accessible tumors disappeared, clinically significant disease progression, or
unacceptable toxicity. This report is a post hoc analysis of the systemic
effects of talimogene laherparepvec in injected lesions and two types of uninjected
lesions-non-visceral lesions and visceral lesions.

Eleven of 23 patients
(47.8 %) had a more than/= 30 % reduction in the total burden of
uninjected non-visceral lesions, and 2 of 12 patients (16.7 %) had a more
than/= 30 % reduction in the total burden of visceral lesions. Among 128
evaluable lesions directly injected with talimogene laherparepvec, 86
(67.2 %) decreased in size by more than/= 30 % and 59 (46.1 %)
completely resolved. Of 146 uninjected non-visceral lesions, 60 (41.1 %)
decreased in size by more than/= 30 %, the majority of which (44
[30.1 %]) completely resolved. Of 32 visceral lesions, 4 (12.5 %)
decreased in size by more than/= 30 %, and 3 (9.4 %) completely
resolved. The median time to lesion response was shortest for lesions that were
directly injected (18.4 weeks), followed by uninjected non-visceral
lesions (23.1 weeks) and visceral lesions (51.3 weeks), consistent
with initiation of a delayed regional and systemic anti-tumor immune response
to talimogene laherparepvec. These results support a
regional and systemic effect of talimogene laherparepvec immunotherapy in
patients with advanced melanoma.

Monday, March 21, 2016

I've posted it a zillion times from all sorts of articles and webinars ~ when dealing with immunotherapy... 'Be patient with the patient!'...(from the webinar by Weber and Agarwala). Repeatedly we've been warned that "progression" and "pseudoprogression" early on has to be evaluated with a grain of salt...rather than considering the measure ineffective and yanking patients off their therapy as one fellow rattie was in my Nivo trial back in 2010 before we learned better. (Though, if you've forgotten....while Weber was looking for another treatment for him...he started to improve!!!! And continued to do so....with no further treatment.) Folks treated with various immunotherapies, and combo's of same, have had side effects that rendered continuation of such treatment impossible. Yet....they continued to respond. Here a cadre of melanoma big dogs look at the results of 655 patients treated with pembro and tell us that as many as 15% of those treated could have had their treatment effect disregarded if old time evaluative criteria continue to be utilized.....

"We evaluated atypical
response patterns and the relationship between overall survival and best
overall response measured per immune-related response criteria (irRC) and
Response Evaluation Criteria in Solid Tumors in patients with advanced melanoma
treated with pembrolizumab in the phase Ib KEYNOTE-001 study.

Patients received
pembrolizumab 2 or 10 mg/kg every 2 weeks or every 3 weeks. Atypical responses
were identified by using centrally assessed irRC data in patients with greater
than/= 28 weeks of imaging. Pseudoprogression was defined as greater than/= 25%
increase in tumor burden at week 12 (early) or any assessment after week 12
(delayed) that was not confirmed as progressive disease at next assessment. Of
the 655 patients with melanoma enrolled, 327 had greater than/= 28 weeks of
imaging follow-up. Twenty-four (7%) of these 327 patients had atypical
responses (15 [5%] with early pseudoprogression and nine [3%] with delayed
pseudoprogression). Of the 592 patients who survived greater than/= 12 weeks,
84 (14%) experienced progressive disease per RECIST v1.1 but nonprogressive
disease per irRC. Two-year overall survival rates were 77.6% in patients with
nonprogressive disease per both criteria (n = 331), 37.5% in patients with
progressive disease per RECIST v1.1 but nonprogressive disease per irRC (n =
84), and 17.3% in patients with progressive disease per both criteria (n =
177).

Atypical responses were
observed in patients with melanoma treated with pembrolizumab. Based on
survival analysis, conventional RECIST might underestimate the benefit of
pembrolizumab in approximately 15% of patients; modified criteria that permit
treatment beyond initial progression per RECIST v1.1 might prevent premature
cessation of treatment."

Way to go, ratties. Teaching the Big Dogs. And dogs...thanks for listening! - c

Saturday, March 19, 2016

When I first spied M7093, I thought these tops would be a cute simple addition to any wardrobe with lots of options. I was thrilled when reviews on patternreview.com (A great source of info on how well a pattern does, or does NOT, come together!) were stellar!! I made my first one out of scraps. I have no earthly idea where the grey substantial knit piece came from. I think I used it to make some sort of a Halloween tadah for the kids years ago. The burgundy bits were pieces left from a T-shirt dress. And while the pattern is technically for wovens....it worked out great!!!

Another bright and shiny morning before work!!!

Future plans!! I already had left-over bits of all the prints pictured here and B helped me find matching fabric last week! Isn't he the best B ever!!! Wonder how much yardage he purchased?????? Hmmmmm..... Sew Chaotically!!! - c